Avoid Missing Out on 25 Crucial MIPS Points: Your Guide to the PI SRA
The Security Risk Analysis (SRA), while seemingly just another box to tick, remains a critical component of the Merit-based Incentive Payment System (MIPS). Though it doesn’t carry a score, its importance cannot be overstated. Overlooking this measure is one of the primary reasons practices fail their audits. In fact, missing this step can cost you all your Promoting Interoperability points, irrespective of your accomplishments in other objectives. That’s because the SRA is essentially a scoreless prerequisite to earn ANY of the points in the PI category, just like SAFER guides.
What is the Promoting Interoperability SRA?
With the rise in digitization, electronic health records (EHRs), and the increasing complexity of healthcare IT systems, ensuring the security and privacy of patient information is of paramount importance. The SRA helps evaluate and mitigate risks to such data. The SRA is an integral part of the MIPS framework, specifically within the Promoting Interoperability performance category. The assessment ensures that healthcare providers identify potential risks in their electronic health information systems and take steps to address them, thereby safeguarding patients' sensitive data.
A comprehensive SRA evaluates all required areas of the administrative, physical, and technical regulatory citations relative to protecting electronic patient health information in your practice. It’s not just about passwords and HIPAA policy.
A thorough SRA includes the following key elements:
Scope Identification: Determine which electronic systems store, process, or transmit protected health information (PHI). This includes EHRs, billing systems, patient portals, and any other relevant systems.
Threat and Vulnerability Identification: Identify potential threats (both internal and external) and vulnerabilities that could harm the confidentiality, integrity, or availability of the PHI.
Assessment of Current Security Measures: Evaluate the effectiveness of the current security measures in place to protect the PHI.
Determination of Potential Impact: Analyze the potential impact on the organization should the identified threats exploit the existing vulnerabilities.
Risk Determination: Assess the level of risk by considering the likelihood of threat occurrence and the potential impact on the organization.
Final Report: Document the findings, actions taken, and any recommendations for future actions.
Periodic Review & Updates: The SRA is not a one-time activity. Healthcare providers need to continuously update and review their assessments, especially when there are significant changes to their IT systems or environments.
For those unaware or just in need of a refresher, here are seven essential facts about the SRA for MIPS in 2023:
Your Responsibility: An SRA isn't performed within your EHR or by its vendor. The onus lies entirely on you.
Beyond Just EHR: The SRA examines ePHI across all office systems, encompassing policies, procedures, and practices.
MIPS Requirements: Eligible MIPS clinicians must affirmatively attest to conducting or reviewing an SRA, making essential security updates, and rectifying identified deficiencies.
Threefold Review: The SRA covers administrative, technical, and physical safeguards in your organization.
Regular Updates: Whenever there's a system upgrade or new installation, an analysis is mandatory. Plus, a review is essential for every MIPS performance cycle.
Managing Risks: Recognize and incorporate any security updates and deficiencies into the clinician's risk management approach. Actions must be taken based on this strategy.
The High Stakes: Neglecting mandatory actions related to the SRA will result in no points in the Promoting Interoperability category, even if you report other measures.
The SRA impact on MIPS performance and overall practice security cannot be overstated. Performing a SRA might seem intimidating, but remember, you don't have to tackle it by yourself. Whether you collaborate with IT vendors, regulatory experts, or even try a self-assessment, the important thing is to be meticulous. Mistakes, such as failing to document compensatory controls for items, could result in point deductions that affect your practice’s financials. By taking on the responsibility, understanding its many aspects, and including its discoveries in risk management plans, you can make sure your practice stays strong even as security challenges change over time.
How Can Chirpy Bird Inc. Assist You?
Chirpy Bird Inc. is here to simplify the process. Our comprehensive 137-point inspection covers administrative, physical, and technical elements, showcasing our attention to detail. We not only help you meet but exceed CMS MIPS policy guidelines, providing comprehensive documentation, detailed reports, and bespoke policies, explicitly curated for your practice.
A dedicated Chirpy Bird regulatory expert will guide you through the results, pinpointing areas needing attention and offering solutions to plug any compliance gaps or address deficiencies.
Remember: The SRA needs an update or completion annually. Don’t wait for the year-end rush; ensure compliance well in advance.
Interested in safeguarding your MIPS points? Schedule your SRA with us today!
hello@chirpybirdinc.com Phone: 888-647-7247
